1. Overview of Urinary Incontinence (UI) in the Long Term Care Facility
Evaluation and Management
Ann M. Spenard RN, C, MSN
Courtney Lyder ND, GNP

2. Learning Objectives Describe common reversible causes of UI
Differentiate between chronic types of UI and describe appropriate treatment options for each diagnosis
Describe evaluation procedures, which are appropriate for establishing diagnosis of UI in the long-term care setting
Describe the process for completing the UI Physical Assessment and History Form
Describe all the components for completing the physical examination for urinary incontinence

3. Steps to Continence 1. Complete Physical Assessment and History form
2. Determine the type of urinary incontinence
3. Complete Algorithm

4. Evaluation is the Key!
Identification of the type of urinary incontinence is the key to effective treatment.

5. Obtaining an accurate and comprehensive UI History

6. Prevalence of Urinary Incontinence
Estimated 10% to 35% of adults
> 50% of 1.5 million nursing home residents
A conservative estimated cost of $5.2 billion per year for urinary incontinence in nursing homes
Estimated that approximately 10% to 35% of all adults in the United States suffer from bladder control problems.
The highest prevalence occurs in the elderly in both community and institutional settings.
50% of 1.5 million nursing home residents are urinary incontinent.
Fant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy and Research AHCPR Publication No National Center for Health Statistics. Vital Health Statistics Series. 13(No. 102). 1989e in

7. Impact on Quality of Life
Loss of self-esteem
Decreased ability to maintain independent lifestyle
Increased dependence on caregivers for activities of daily life
Avoidance of social activity and interaction
Restricted sexual activity
Although urinary incontinence is classified as a medical disease, it most importantly affects:
quality of life
self-esteem
social activities
alters daily functioning
Grimby et al. Age Aging ; 22:82-89.
Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. Washington DC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988.
Noelker L. Gerontologist ; 27:

8. Consequences of UI An increased propensity for falls
Most hip fractures in elders can be traced to nocturia especially if combined with urgency
Risk of hip fracture increases with
physical decline from reduced activity
cognitive impairments that may accompany a UTI
medications often used to treat incontinence
loss of sleep related to nocturia
Falls and hip fractures are very common in the elderly population and are often the reasons for prolonged hospitalization and admission to a long term care facility.
Rushing to the bathroom is frequently the cause of a fall.
Nocturia is defined as getting up to the bathroom more than twice during the night.

9. Risk Factors Aging Medication side effects High impact exercise
Menopause
Childbirth
There are many different things that put a person at risk for incontinence.
These are risks for incontinence, not causes.

10. Factors Contributing to Urinary Incontinence
Medications
Diuretics
Antidepressants
Antihypertensives
Hypnotics
Analgesics
Narcotics
Sedatives
Diet
Caffeine
Alcohol
Bowel Irregularities
Constipation
Fecal Impaction
Side effects of many medications can significantly contribute to bladder control problems, along with irritants such as caffeine.
antihypertensives include medications such as calcium channel blockers, beta adrenergics, and diuretics.
hypnotics include psycatropic and psychoactive, in addition to drugs with adrenergic side effects.
Some foods that are thought to contribute to bladder leakage include:
alcoholic beverages
carbonated beverages (with or without caffeine)
milk or milk products
coffee or tea (even decaffeinated)
citrus juices and fruits
tomatoes
highly spicy foods
sugar and honey
chocolate, corn syrup and artificial sweeteners

11. Age Related Changes in the Genitourinary Tract
Majority of urine production occurs at rest
Bladder capacity is diminished
Quantity of residual urine is increased
Bladder contractions become uninhibited (detrusor instability)
Desire to void is delayed
Normal changes that occur with the aging process can also put a person at risk for bladder control problems.
Residual urine is the amount of urine left in the bladder after a void.
normally less than 100cc.
many elderly people have larger amounts left in the bladder after a void, even though they demonstrate no signs of this. That is, they do not feel full or uncomfortable, that have good urine output, and do not seem to have a large bladder by palpation or percussion.

12. Types of Urinary Incontinence
Stress
Urge
Mixed
Overflow
Total

13. Types of Urinary Incontinence
Stress: Leakage of small amounts of urine as a result of increased pressure on the abdominal muscles (coughing, laughing, sneezing, lifting)
Urge: Strong desire to void but the inability to wait long enough to get to a bathroom
Stress incontinence
can also occur when a resident is being moved, for example when transferring from chair to bed, or wheelchair to toilet.
It is caused by weakness or damage to the pelvic floor or urethra.
Urge incontinence
caused by detrusor muscle weakness, damage, or hyperactivity.

14. Types of Urinary Incontinence (continued)
Mixed: A combination of two types, stress and urge
Overflow: Occurs when the bladder overfills and small amounts of urine spill out (bladder never empties completely, so it is constantly filling)
Total: Complete loss of bladder control
Mixed incontinence
most common in the elderly.
Overflow incontinence
caused by neurological factors or obstruction, such as benign prostatic hypertrophy (BPH).
obstruction can also occur in females due to prolapse of the uterus.

15. Urinary Incontinence can
Remember...
Urinary Incontinence can
be treated even if the resident has dementia!!

16. Cause of Stress Urinary Incontinence
Failure to store secondary to urethral sphincter incompetence
Stress incontinence
usually associated with weakening of the supporting tissue surrounding the bladder neck and urethra.
this damage can be the result of
pregnancy
vaginal deliveries
trauma during GYN or urologic surgery
obesity
chronic coughing
while stress incontinence is uncommon in men, it can occur as a result of injury to the sphincter during prostate surgery or radiation therapy.

17. Causes of Urge Urinary Incontinence
Failure to store, secondary to bladder dysfunction
Involuntary bladder contractions
Decreased bladder compliance
Severe bladder hypersensitivity
People with urge incontinence may experience inappropriate contractions of the detrusor muscle during the storage phase of the micturition cycle.

18. Stress Incontinence vs. Urge Incontinence: System Check List

19. Causes of Mixed Urinary Incontinence
Combination of bladder overactivity and stress incontinence
One type of symptom (e.g., urge or stress incontinence) often predominates
Mixed incontinence is very common in the geriatric population.

20. Symptoms of Overactive Bladder
Urgency
Frequency
Nocturia, and/or urge incontinence
ANY COMBINATION - in the absence of any local pathological or metabolic disorder

21. Causes of Overflow Urinary Incontinence
Loss of urine associated with over distention of the bladder
Failure to empty
Underactive bladder
Vitamin B12 deficiency
Outlet obstruction
Enlarged Prostate
Urethral Stricture
Fecal Impaction
Neurological Conditions
Diabetic Neuropathy
Low Spinal Cord Injury
Radical Pelvic Surgery

22. Neurogenic Bladder What is a neurogenic bladder?
A medical term for overflow incontinence, secondary to a neurologic problem
However, this is NOT a type of urinary incontinence

23. Basic Types and Underlying Causes of Incontinence
Local GU conditions include:
cystitis
urethritis
tumors
stones
diverticuli
outflow obstruction
CNS disorders include:
stroke
dementia
parkinsons
suprasacral spinal cord injury or disease
Vit B12 deficiency:
biggest reason for overflow incontinence.
affects the maturation of the erythrocytes.
diagnosis is confirmed by a reduced erythrocyte count and a peripheral blood smear that demonstrates megoblastic maturation. Confirmation of the megoblastic, macrocytic type of anemia is established by an increased MCV about 94 microns and increased MCH above 30ug and a normal MCHC on the CBC.

24. Reversible or Transient Conditions That May Contribute to UI
“D” Delirium
Dehydration*
“R” Restricted mobility Retention
“I” Infection
Inflammation
Impaction
“P” Polyuria
Pharmaceuticals

25. *Dehydration
Dehydration due to decreased fluid intake; increased output from diuretics, diabetes, or caffeinated beverages; or increased fluid volume due to congestive heart failure can concentrate the urine (increased specific gravity) and also lead to fecal impaction
The specific gravity of the urine can be tested to determine whether or not the resident is dehydrated
Normal specific gravity range is to It is increased in dehydration.

26. Basic Evaluation Physical Exam Female genitalia abnormalities
Rectocele
Urethral Prolapse
Cystocele
Atrophic Vaginitis

27. Basic Evaluation for Differential Diagnosis
Patient History
Focus on medical, neurological, genitourinary
Review voiding patterns and medications
Voiding diary
Administer mental status exam, if appropriate
Physical Exam
General, abdominal and rectal exam
Pelvic exam in women, genital exam in men
Observe urine loss by having patient cough vigorously

28. Basic Evaluation for Differential Diagnosis (continued)
Urinalysis
Detect hematuria, pyuria, bacterimia, glucosuria, proteinuria
Post void residual volume measurement by catheterization or pelvic ultrasound

29. Lab Results Lab results from approximately the last 30 days:
Calcium level normal mg/dl
Glucose level normal fasting mg/dl
BUN normal mg/100 ml (OR)
Creatinine normal mg/dl
B12 level (within the last 3 years) normal pg/ml
*Normal lab values may vary depending on laboratory used.

30. Three Day Voiding Diary
Three day voiding diary should be completed on the resident
Assessment should be completed 24 hours a day for 3 days
Make sure CNA’s are charting when the resident is dry or not, the amount of incontinence, if the voiding was requested or prompted

31. Basic Continence Evaluation
Focused Physical Exam, including:
Pelvic exam to assess pelvic floor & vaginal wall relaxation and anatomic abnormalities including digital palpation of vaginal sphincter
Rectal exam to rule out fecal impaction & masses including digital palpation of anal sphincter.
Neurological exam focusing on cognition & innervation of sacral roots 2-4 (Perineal Sensation)
Post Void Residual to rule out urinary retention
Mental Status exam when indicated

32. Simple Urologic Tests Provocative Stress Testing Key components
Bladder must be full
Obtain in standing or lithotomy position
Sudden leakage at cough, laughing, sneezing, lifting, or other maneuvers

33. Female Exam of Urethra and Vagina
During a bed side exam the nurse should observe for the following:
The presence of pelvic prolapse (urethroceles, cystoceles, rectoceles)
It is more important that you identify the presence of a prolapse than the particular type
Is the vaginal wall reddened and/or thin?
Is the vaginal wall atrophied?
Is there abnormal discharge?

34. Female Exam of Urethra and Vagina (continued)
Test the vaginal pH by taking small piece of litmus paper and dabbing it in the vaginal area
Document the vaginal pH
If the pH is >5 it is a positive finding

35. Dorsal Lithotomy Position (Normal Vaginal Area)

36. Male Exam of the Penis
Is the foreskin abnormal? (Is the foreskin difficult to draw back, reddened, phimosis)
Phimosis is a general condition in which the foreskin of the penis can not be retracted
Is there drainage from the penis?
Is the glans penis urethral meatus obstructed?

37. Male Genitalia

38. Phimosis

39. Rectal Exam Nursing staff should perform a rectal exam
Document if the resident has a large amount of stool or the presence of hard stool

40. Prostate Exam
While completing a rectal exam for constipation, note if you feel the prostate enlarge
Please note findings

41. The Bulbocavernous Reflex Test
When the nurse is inserting a finger into the anus to check for fecal impaction, the anal sphincter should contract
When the nurse is applying the litmus paper to check the vaginal pH, the vaginal muscle should contract
(When both these muscles contract this indicates intact reflexes)

42. Post Void Residual
A post void residual should be obtained after voiding via a straight catheterization or via the the bladder scan
If the resident has > 200 cc residual the test is positive
(Document the exact results on the assessment form)

43. Mini Mental Exam (MMSE)
Complete a mini mental exam on the resident
Chart the score on the assessment form
Score the resident on the number of questions they answered correctly to the total number of questions reviewed

44. Basic Evaluation Rectocele
Anterior and downward bulging of the posterior vaginal wall together with the rectum behind it
A rectocele
formed by the anterior and downward bulging of the posterior vaginal wall together with the rectum behind it.
to identify it, spread the resident’s labia and ask her to strain down.
Nursing assistants can also help identify when a rectocele is present by evaluating the resident when the resident is straining at stool.

45. Rectocele

46. Basic Evaluation Urethral Prolapse
Entire circumference of urethral mucosa is seen to protrude through meatus
Urethral prolapse
when entire circumference of the urethral mucosa is seen to protrude through the meatus.
this is commonly seen with atrophic vaginitis.

47. Urethral Prolapse

48. Basic Evaluation Cystocele
Anterior wall of the vagina with the bladder bulges into the vagina and sometimes out of the introitus
Cystocele:
anterior wall of the vagina with the bladder bulges into the vagina and sometime out of the introitus.
look for the bulging vaginal wall as the patient strains down. This is the most common type of prolapse. Often a pessary is used to treat it.

49. Distension Cystocele

50. Basic Evaluation Uterine Prolapse
The uterus falls into the vaginal cavity

51. Uterine Prolapse

52. Huge Prolapsed Cervix

53. Basic Evaluation Atrophic Vaginitis
Thinning of vaginal and urethral lining causing dryness, urgency, decreased sensation

54. Advanced Postmenopausal Atrophy

55. Treatment
Guidelines recommend least invasive evaluation and treatment as baseline!!

56. Treat Transient Causes First
Such as:
Atrophic vaginitis
Symptomatic urinary tract infections (UTI)

57. Hypoestrogenation Causes (Loss of Estrogen)
Decreased glycogen
Decreased lactic acid
Increased vaginal pH
Increased risk of UTI’s

58. Urinary Tract Infections (UTI)
The vaginas of postmenopausal women not being treated with estrogen have been found to be predominately colonized by E. coli

59. Circulating Estrogen Inhibits Uropathogen Growth by:
Colonization of the vagina with lactobacilli
Maintenance of acidic pH (<5)

60. Positive Effects of Estrogen Replacement
A decrease in vaginal pH
Reemergence of lactobacilli
Colonization of the vagina rarely occurs when the pH is below 4.5

61. Symptoms tend to re-appear when estrogen treatment ends!
Effects of local estrogen (short lived urinary symptoms related to atrophy) tend to reappear several weeks after treatment ends.

62. Other Treatments of Urinary Incontinence
Behavioral therapy
Pharmacotherapy
Electrical Stimulation
Denervation/decentralization
Augmentation cystoplasty
Catheterization
Urinary diversion
These are listed in descending order. Lease invasive to most invasive. Pads and absorbent products are used to manage urinary incontinence NOT to treat.

63. Behavioral Treatments
Fluid management
Voiding frequency
Toileting assistance
Scheduled toileting
Prompted voiding
Bladder training
Pelvic floor muscle exercise
Other behavioral treatments include careful fluid management.
Residents can become incontinent due to dehydration. Concentrated urine with a specific gravity >1.030 indicates that a resident is not drinking enough fluids.

64. Bladder Training & Urgency Inhibition Training
Bladder Training - techniques for postponing voiding
Urge Inhibition Training - techniques for resisting or inhibiting the sensation of urgency
Bladder training & urge inhibition training is strongly recommended for urge & mixed incontinence & is recommended for management of stress incontinence

65. Behavior Treatments Pelvic muscle exercises Effects of exercises
Support, lengthen and compress the Urethra
Elevate the urethrovesical junction
Increase pelvic/muscle tone

66. Behavior Treatments Pelvic muscle (Kegel) exercises
Goal: to improve urethral resistance and urinary control through the active exercise of the pubococcygenus muscle
Components:
Proper identification of muscle (if able to stop urine mid-stream)
Planned active exercise (hold for 10 seconds then relax) times per day for a minimum of 8 weeks

67. Biofeedback
Very helpful in assisting patients in identifying and strengthening pelvic muscles
Give positive feedback for bladder training, habit training and/or Kegels

68. Pharmacotherapy Medications
To relax or augment bladder or urethral activity

69. Inserts
Pessary
Urethral inserts
Vaginal weights

70. Pessary

71. Surgical Treatment (Last Choice)
More than 100 techniques
Repair hypermobility
Repair urethral support
Contigen ™ implants (ISD)

72. When do you Refer to a Specialist?
Uncertain diagnosis/no clear treatment plan
Unsuccessful therapy/resident requests further therapy
Surgical intervention considered/ previous surgery failed
Hematuria without infection

73. Referral to Specialist (continued)
Existence of other comorbid conditions:
Recurrent symptomatic urinary tract infection
Persistent symptoms of difficulty with bladder emptying
Symptomatic pelvic prolapse
Prostate nodule enlargement, asymmetry, suspicion of cancer
Abnormal post void residual urine
Neurological condition: multiple sclerosis, spinal cord lesion/injury
History of previous radical pelvic or anti-incontinence surgery

74. Indwelling Catheters
Indwelling catheters (urethral or suprapubic) may be necessary for certain residents with incontinence:
Urinary retention that cannot be corrected medically or surgically, cannot be managed by intermittent catherization and is causing persistent overflow incontinence, symptomatic UTIs
Pressure ulcers or skin lesions that are being contaminated by incontinent urine
Terminally ill severely impaired residents
When a foley is removed it takes three days to retrain the bladder. During this time, it will be necessary to use intermittent catheterizations.

75. Summary
With correct diagnosis of UI, expect more than 80% improvement or cure rate without surgery!!

76. Evaluation is the Key!
Identification of the type of urinary incontinence is the key to effective treatment.

77. Case Study 1
Mrs. Martin:
She was admitted to a skilled nursing facility following a hospitalization for surgical repair of a fractured hip which occurred when she fell on the way to the bathroom.

78. Prior to Admission:
She was living at home with her daughter. Her medical history included hypertension and osteoporosis. Mrs. Martin’s daughter reported that her mother frequently rushed to get to the bathroom on time and often got out of bed 4 to 5 times per night to urinate.

79. Upon Admission to the Nursing Home:
A physical therapy evaluation was done to assess Mrs. Martin’s transfer status. The therapist recommended assistive ambulation and the nursing staff implemented an every 2 hour toileting schedule. This resident’s MDS continence coding score after 14 days was 3 (frequently incontinent).

80. Upon Admission to the Nursing Home: (continued)
Mrs. Martin stated that she knew when she needed to void but could not wait until the staff could take her to the bathroom. She could feel the urine coming out but could not stop her bladder from emptying. Mrs. Martin felt embarrassed about wearing a brief but felt it was better than getting her clothing wet. Her incontinence was sudden, in large volumes and accompanied by a strong sense of urgency.

81. Problem Identification
The problems identified by the staff during the first case conference included urge incontinence and impaired mobility.